Provider Demographics
NPI:1609397934
Name:LOTT, MALLORY STEWART (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:STEWART
Last Name:LOTT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:MCKIE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10718 COUNTRYWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1733
Mailing Address - Country:US
Mailing Address - Phone:813-844-4800
Mailing Address - Fax:
Practice Address - Street 1:10718 COUNTRYWAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1733
Practice Address - Country:US
Practice Address - Phone:813-844-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9362485363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9362485OtherARNP